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HomeMy WebLinkAboutBLDG-21-000822 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I ‘4,0"; CITY YARMOUTH MA DATE 'August 19,2020 I PERMIT# BLDG-21-000822 JOBSITE ADDRESS 62A PLEASANT ST OWNERS NAME DAVENPORT DEWITT P G OWNER ADDRESS DAVENPORT SUSAN E 20 NORTH MAIN ST SOUTH YARMOUTH MA 02664-3150 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 NO 111 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND ❑ OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ANDREW LEVESQUE LICENSE# 15162 SIGNATURE MP©MGF❑JP 0 JGF❑ LPG' ❑ CORPORATION❑# I PARTNERSHIP ❑#I ILLC❑# COMPANY NAME: HARWICHPORT HEATING AND COOLING ADDRESS. 461 LOWER COUNTY ROAD, CITY HARWICHPORT STATE MA ZIP 02646 TEL I FAX CELL I I EMAIL andy(dhphclIc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mr, • CITY YARMOUTH MA DATE 8/14/2020 PERMIT# AL - ".", 4' - "-2 JOBSITE ADDRESS4 64 EASANT STREET OWNER'S NAME DAVENPORT G OWNER ADDRESS 60 PLEASANT STREET TEL 508-398-2293 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL ❑ RESIDENTIAL (X PRINT CLEARLY NEW: n RENOVATION: ❑ REPLACEMENT: (X PLANS SUBMITTED: YES ❑ NO APPLIANCES - FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _FURNACE ATTIC 1 GENERATOR _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER _ , _ROOM / SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER _ _ UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES LVNO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Fv7 OTHER TYPE INDEMNITY BOND n OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER n AGENT n SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,-<z,z-,--_4-/:_z_-- PLUMBER-GASFITTER NAME Andrew Levesque LICENSE # PL15162 GNATUS MP [i MGF ,' JP ❑ JGF ri LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC Q(# 3944 COMPANY NAME Harwich Port Heating & Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy@hphcinc.dom 1 AUG 17 2020 BUILDING DE.PA--:, N,:IL 4 1 By — ---- -- .j r i i i i The Commonwealth of Massachusetts , r Department of Industrial .. :t Office of Investigations 1 1 t - �1�,��, y 600 Washington Street "t:�! `` Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly t Name(Business/Organization/Individual): Harwich Port Heating&Cooling LLC Address: 461 Lower County Road • i n i City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 ` 4 r Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with Ira 4. ❑ I am a general contractor andl 6. P New construction i£ employees(full and/or part-time).* have hired the sub-contractors 2.El I am a sole proprietor or partner listed on the attached sheet. 7. [1 Remodeling 1 . 3 ship and have no employees These sub-contractors have 8. El Demolition Demolition i k. working for me in any capacity. employees and have workers' 4. g Building addition [No workers'comp.insurance comp.insurance.: required.] • 5. ❑ We are a corporation and its 10.g Electrical repairs or additions 3.❑T am a homeowner doing all work officers have exercised their 11.2 Plumbing repairs or additions U myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs iI insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.P Other HVAC _ 1 i comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy 11 or Self ins.Lic.#i: WC9059813 Expiration Date: 10/26/2020 I 60 PLEASANT STREET City/State/Zip:/State/Zi Job Site Address: tY p: YARMOUTH I Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of i Investigations of the DIA for insurance coverage verification. !. 11 I do hereby certify rind • a d penalties ofperJury tltat the information provided above is true and correct. 1 Signature: - Date: 8/14/2020 Phone#: 508-432-3959 • 1 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License## . ___ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: • jt